Usually the left side of the heart is affected first, and this invariably leads to failure in the right side, the portion of the circulation that delivers blood through the lung system.
This is an early and cardinal sign. A cough is common, and frequently the material brought up is tinged with blood. This is termed hemoptysis. This is the typical set of symptoms.
Breathlessness is referred to clinically as dyspnoea. All levels are experienced. In the initial stages of failure, “effort dyspnoea” is the earliest indication, coming on only with severe exertion. However, as cardiac efficiency decreases, so dyspnoea increases. The threshold of effort needed to bring on breathlessness gradually lowers, so a gradual lessening of physical activity will produce symptoms.
Progressively, it becomes noticeable mainly toward evening, and the simple effort of undressing may produce it. Sleep at night often brings relief, and in the morning a good start may be made to another day. With advancing disease, breathlessness even at rest may take place, and simple efforts involved in speaking, gesturing or making any movement may precipitate dyspnoea. The respiratory movements are shallow, quick and obviously troublesome, and accompanied by much effort. They are never sighing or deep, and are not relieved if the attention is suddenly diverted to something else.
With the progression of time, the patient develops a condition called orthopnoea. This means that breathing difficulty occurs at night during sleep. When the patient is in the recumbent position, a build-up of fluid occurs in the lungs. This reduces the ability to secure adequate oxygenation of the blood.
This may cause the sufferer to awaken with dyspnoea. Often he or she will find it better to sleep propped up with pillows, or even to remain propped up in an easy chair instead of lying flat.
This nocturnal difficulty may suddenly get out of hand, and a condition called paroxysmal cardiac dyspnoea (also commonly called cardiac asthma) may follow. This is an extension of orthopnoea, and it is frequently a striking feature late in heart failure.
The symptoms may be of any degree of severity. Most attacks occur at night, and lying in the recumbent position appears to be the immediate aggravating factor. The inadequacy of the heart as a pump allows a build-up of fluid in the lungs, aggravated by the gravitational flow of blood to the lungs in this position.
This is more common after a hard day’s work and a large evening meal. The patient will suddenly awaken about 2 am with a sense of suffocation and dyspnoea. Gripped with an intense desire to get out of bed, he or she invariably does this at once, and going to the window, throws it open, endeavoring to inhale deeply in an effort to get adequate oxygen into the lungs. There is a sense of constriction in the chest; coughing is common, and often blood-stained fluid is brought up. Breathing may become extremely difficult, and a wheeze, very much like the wheeze of the asthmatic, occurs. The patient is anxious, tense and drawn, and often fears for his or her life. The skin may be pale and cold. Often, the standing position in itself assists in mechanically bringing relief.
A disorder named pulmonary edema is a more severe form of this condition. Often there is pain over the chest, breathing is noisy, and there is coughing and the production of much blood-stained, watery fluid. Sometimes a bluish tinge occurs as inadequate oxygen enters the circulation. Mental confusion can frequently follow from inadequate oxygenation of the higher centers in the brain. This constitutes a medical emergency, and prompt treatment is essential. In advanced cases, a typical breathing pattern develops, referred to as Cheyne-Stokes respiration. Each breath commences as a very shallow inspiration. These gradually increase in depth and speed, until they are forceful and deep. The blood becomes oversupplied with oxygen, and there is then a temporary lull, or gradual reduction in the inspiratory movements. Advanced cases are often associated with irregularities of the heartbeat, and abnormal sounds in the chest and heart.
This is the accumulation of fluid in dependent parts, a common occurrence in heart failure, and indicates that the right side of the heart is reducing in efficiency.
This was once commonly referred to as dropsy, and is a typical symptom of a failing heart. Swelling takes place in dependent parts of the body, the ankles being the most common. But it may occur low down in the back, in the so-called sacral area, about the genital region and in the upper thigh areas.
This is merely another indication that the heart is not pumping all the blood that is being delivered to it and blood is building up on the venous side.
If a person is standing all day, the fluid tends to accumulate about the ankles. Toward the end of the day (or at any time of day in more advanced cases), the ankle disappears altogether. If a finger is pushed into the tissue and then removed, an indentation occurs that may take several minutes to smooth out. It is a bit like poking a finger into a piece of putty. The tissue underneath is saturated with fluid, and indentations from outside pressures remain. Wearing tight shoes or socks will also leave their pattern indented on the swollen part.
Usually, with rest at night, and the feet elevated, the edema tends to vanish by morning, but gradually develops as the day progresses.
Often the degree of edema is a good indication as to the effectiveness of therapy, and lets the doctor know if the treatment is working. Fluid tends to be removed, and the heart often improves in Palpitation (premature beat). Incomplete heart block Typical electrocardiogram (ECG) tracings, made by an electrocardiograph and used in diagnosing irregularities of heart action efficiency with the administration of certain drugs.
Sometimes other internal organs are similarly filled with fluid. The circulation to the intestinal region and liver may be involved. For this reason, the liver may be swollen, and the vessels of the bowel tense and engorged. Appetite may be depressed due to this.
In more advanced stages, fluid tends to seep out into the general abdominal space, accumulating by gravity in the lower regions. This is known as ascites, and is usually a serious indication of advanced cardiac disease.
Other Heart Failure Symptoms
Many other symptoms may be present. Fatigue and exhaustion may occur. Sometimes, a bluish tinge of the lips and extremities and other skin surfaces may indicate inadequate oxygenation of the general blood supply. This will be aggravated if anemia is also present.
The doctor will frequently order various tests that give an indication of the severity of the disease. X-rays will often show enlargement of the chambers of the heart, as they distend and become less efficient. The lungs may show marked congestion, as excessive amounts of fluid accumulate there. The electrocardiogram will also indicate that the heart is not operating efficiently.
Heart Failure Treatment
There are wide variations in the clinical picture of heart failure. It commences as a disorder without symptoms, and gradually (or rapidly) develops into a more serious condition.
The sooner any underlying cause can be found and corrected, the better are the chances of stemming the deterioration. Often other concurrent disorders are present, and can be diagnosed and corrected.
These may include diseases of the heart valves, thyroid disease (thyrotoxicosis, a potent troublemaker), beriberi (often from excessive alcoholic intake) or anemia. However, once established, general principles of treatment follow. These are basically aimed at resting the disordered heart muscle. Physical and mental rest can only assist in allowing the heart to carry out its actions as efficiently as possible without undue outside interference of an artificial kind.
Next, the efficiency of the heart must be improved as much as possible and the tendency to accumulate fluid and salts must be actively treated by the use of fluid-removing tablets, commonly the oral diuretics, now in wide use.
This is important. The amount required will depend on the extent to which the disorder has advanced. If bouts of cardiac asthma are recurring, then with each attack bed rest may be required for a few days.
Physical and mental rest alleviates anxiety and worry; physical repose reduces the amount of work the heart muscle must perform each day. Treatment of the cardiac patient is under the care of a physician.
There is always a fear that doctors keep well in mind. With prolonged rest in bed, and lack of movement, there is an increased risk of clots forming. The calf muscles are a favorite site for this condition, referred to as deep venous thrombosis. Apart from causing marked swelling of the affected limb, a piece of clot may break off and block a major segment of the lung, and this is a serious but ever-present possibility. Often a compromise is made between bed rest and partial ambulation or sitting on a chair.
This is given consideration. With rest, there is less need for large meals, and a 4200 kJ (1000 calories) a day food intake is adequate in the initial stages of therapy. Often the patient does not feel hungry, so that a reduction in food intake is seldom a hardship. Meals must be small but attractively served, for there is always a psychological overlay and the patient needs a certain amount of nutrition. Smaller meals mean that the heart works less in coping with this.
Attention is given to the salt content of food, and a low-salt regimen is sometimes recommended. It is suggested food be served without the addition of salt. Often salt-free food is unpalatable. In the past, many diets have been advocated with severely restricted salt routines. Today, with the extreme efficiency of the fluid-eliminating medication (the oral diuretics), not so much attention is being paid to the need for salt restriction.
There is no need to restrict fluid intake. Some doctors (but not all) believe that there is little reason to eliminate alcoholic beverages from the routine purely for reasons of cardiac health. But on moral grounds, and on the grounds of general health, abstinence may well be justified.
Tobacco use in all forms must be restricted or preferably entirely stopped. The adverse effects of the drugs contained in tobacco smoke and their serious effect on the heart and blood-vessel system arc too well documented for smoking to be permitted. It is best to explain this in a kindly way to the patient, who may suffer adversely in the early stages from such deprivation.